WEB SITE: www:state.nh.us/medicine ERD
KEVIN R, COSTIN, PAC
President
JAMES G. SISE, M.D.
Vice President
PLEASE COMPLETE AND RETURN TO THE BOARD OF MEDICINE,
AS SOON AS POSSIBLE, PLEASE PRINT.
*ANOTE.....Please mark the box next tothe address you would prefer to list as
your mailing address.
Physician Name: him € aamppecd.
Business Name: Covey) Pema ener Coun G_ -
X] Address: aE SwTe- MA Sv
Con co RI iit 8 230/
Office telephone: 603-22S—293 7
Business Fax Number: 603-228-625 Ss E-Mail: _
Home telephone: _* «
Speciatty: OB “GY VV Board certified: “756 19 76, 2006
Hospital affiliations: MoPTA- SLE MébicAc Cév¥eX, ZACEM
mb LYusl Mtr PART uekS Hehe T Cake.
In what other states do you hold a current license: ff Ae _ Application for Physician Licensure
OM PHYS ce ryen
JUL 19 2097 3
sano.
4, Name: Indicate your full legal name. If your name has changed at any time during your life and you are
FCVS, you must submit a copy of the legal document (marriage certificate, divorce decree, etc.) supporting your name
change.
1. Full Name (use no initials)
Sufix mY
Mom 000
MLA
Alvother names used
LastName CAMPBELL
Fiest Name EZALAL
Middle Name_ 4 & STER
Maiden Name__ 4”
2. Address/Phone: Please complete all sections and indicate which address you wish to be used for public access
‘and which is to be used for mailings from the medical board. Each state's law determines whether each address or
phone number is a public record in the state in which you are applying. You may wish to contact the licensing authority
for that state for further information. Many boards publish the “Public Access” address on their website, therefore you
should consider what your preferred address is for these purposes.
Practice Address
[Public Access
[Malling
Home Address
CPubiic Access
mailing
ATLAN TICHRE 98-6 Yr
sweet Bosfod ST STE J
ciy ZA ns ___staterProvinee MA ___z1p cove 2° 20%
Telephone__T8/- S 4. 9- 3000
fx BI=S9I-9@IS
Ww,
E-mail address _
Alternate Phone (e.g. pager or cell phone) _
Steet - —
city _ State/Province
Telephone = “
Fax
E-mail address
Alternate Phone (¢.9. pager or cell phone)
ZIP Cod
Applicant Name:
‘Common License Application Form
Page 1
_ CAMPBELL, Ach A
Date: AeeY 1 200. 3. Identification: If you are not using FCVS, you must submit either 2 notarized copy of your birth cerlficate or a
Notarized copy of your current, valid passport.
3. Identification
Date of Birth sith Giy «Cth StSte/Province ————~Bith Country
(mvadlyyyy)
Gender Social Secunty Numpet Are youa US. Citizen? — Clyes BINo
Ghee CALD AYIKIOS SE
‘You sci secu nunber ie equed to acts fporing to the odes Hesltncre itagrty& Praseton Daa Bank (62 JSC. cacons 12200
Tih SUS. Sectn Sea, ond 49 CR, pt) ander ascuns ancaon under ha feces ana ate ed support enforcement (2
USC. Secton 666 and ppleabie eat lau). h may alta be uted for teporing to he National Practoner Osta Bank (82 U.S.C. Section 11101 and
{5 CLR. pt 0) and for ober veatgotvetnfrcomet urpoees a compance wih stats avs governing. prysisen asciping as three
required by stats o araave
4, Medical Schoo: List all medical schools you have attended, even those from which you did not graduate in
chronological order. Attach an additional sheet if necessary. If you are not using FCVS, you must complete the
attached "Medical Education Verification’ form and send it to all medical schools you have attended. You must include
22 copy of your diploma to which the medical school must attach their seal prior to forwarding ito this Board.
Additionally, the medical schoo! must provide this Board with an official copy of your transcripts. The medical schoo!
must forward all documentation directly to this Board,
4, Medical Schoo! (attach additional pages if necessary)
1. School Name__ SCHfowt. OF Mebperwe, MeGize SN VvEe3t 7;
address Me Tv ri ge Buledie, 3655" PepmewAde- S/R WiewAmosceh
ity. Dou vhe Ae
steterProvince _@0UGhEQ
zp code #36 1YG
Country. CANADA
Altendance-Dates grn—my__-929T 1942 40M 194
Graduation Date__INAL_ 34 194 lo
Degree M.D. Com -- Ms Ser smmet 1S ALI206S
2. School Nam
Address
City
‘State/Province.
ZIP Code_
Country
Attendance Dates (rm —1o)
Graduation Date,
Degree
lo
Applicant Name: CAMPBEL, ALA & date Wet 1%, DONE
Common License Application Form
Page 2 usine FCVS
5, Fifth Pathway: If you attended a Filth Pathway program and are not using FCVS, you must complete the attached
“Fifth Pathway Verification’ form and send it to your medical school and to the institution where you completed your
rotations, You must inciude @ copy of your diploma, The medical schoo! and institution must forward all documentation
directly to this Board.
5. Fifth Pathway (if applicable)
Medical School ome fp
Address
city _
State/Province.
21P Code :
Country _ =
Attendance Dates fen 7 _
Graduation Date
Degree _
Institution name where rotations performed
‘Address.
city.
State/Province
2IP Code
County
Atendance Dates emmy
Certification Date
‘opicontine. CAMPBELL, Aemrn/ © Oe ued if, ave
‘Common License Application Form
Page 3 6, Postgraduate Training: List all postgraduate programs you have attended, even those you did not complete.
‘Attach an additional sheet if necessary. If you are not using FCVS, you must complete the attached "Postgraduate
Training Verification” form and send it to all postgraduate training programs you have attended. You must submit @ copy
of your certificate of program completion to this Board. Additionally the postgraduate program must provide this Board
with the Program Director's recommendation letter. The postgraduate program must forward all documentation directly
to this Board.
6. Postgraduate Training (copy and atach additonal gages necessary)
Complete name and address of hospital where training was conducted (Do Not Abbreviate)
‘\Hospital Name_-lew? si GeweeAL Maspeine_, Teachuit hap iTah ol Me Gres newness 74
Hospital Address SESS Core s7e-Carwenie Kod
oly ow ree AL
StaterProvinee _QUE-hee —
ZIP Code H3BTiEem
‘Country CA ADA
STRAIGHT
PGY: (e9.,1, 2,3, etc.) intemship (Residency () Fellowship ClResearch (Other
DepartmentiSpecialty: OB-GYV , creprred As Aescdewcy [|
From: 1192S
c
To: (2-1 /9 He Successhily Completed? Yest® NoC] In Progress(|
‘Month ear Me
jonth Year
2.Mospital Na CELE, LAT AL Ta -MoGin, Un.
Hospital Address /650 CebAR Ave.
city Mouvee re :
StatefProvincee —@ U¢.bS C~
zp coe H 2G | AY
county _ CANA DA
‘STRMOHT.
PGY: (e.9.,1,2,3,et.) internship Cl Residency C) Fellowship 1 Research ) other
DepartmentSpecialty OB-GYN —chenired Ae fescoswey /
2B GIN _cheprred
Frome | 19% F# Tfow&! 19-2 FE _ Successhully Completes? YesKL NoC] In Progress(]}
Month Year Month Year
Applicant Name: Carn PBELL. emia) Date:
Common License Application Form
Page 4 6. Postgraduate Training (continued)
anisintiane Aree Deed of mewreeae - pul nanesed
Hospital Address 37D ST VARA FE
city Map zKEAt_ - -
staterProvinee KM UELEC a
ZIP Code AW ITB = -
couty__ CAA ADA =
Poy: e9.1Qs.e) Ciinternship Residency (Fellowship C] Research []Other
Department/Specialty: @ewekAt _svAGERY
Fromfoesi I94#F to: Nee 1 /GP#L Successfully Completed? Yes]. NoL] In Progress()
Month Year Month Year
‘Hospital Nane__ZZovee Dill oF han EAC _- ONIN oC Mavyrete|
Hospital Addrese_ VO Sy-YREALAI =>
city MIN TLE
sateProvnce__UUELEC _
ZIP Code Haw 1TH
County CANADA :
PGY: (eg., s. etc.) Clintemstiip (& Residency (Fellowship (] Research Clother
Departmentspediany. ROL OG ¥
From MAM /P FE 10: MALY 19 ZF successtily Completes? Yes 8} NoCI In Progress C)
‘Month Year Month Year
Applicant Name: CAMPBELL PLZ AI C— date:
Common License Application Form
Pages. 6. Postgraduate Training (continued) —
Gromtanane 37 = JOST/WE wasirecte, Lnmsts ty of mugnessd
&
Hospital Address 3/F#S” Gaye spe - OATHEOVE A a
iy, MaurheAc_ 7 _
staterProvince SEALE?
ZIP Code, #37 (CS
Country CANADA
PCY: (e.9..1@a.et0) Clinternship PaResidency C} Fellowship C)Research [jother
Departmenv/Speciaity: MTR M AE MEDICALE WI 28 -“GyAl
From ABiLt /P2F To: JywE! (PEF _ successtuly Completed? Yes NoC] in Progress]
Month Year Month Year
fparosptal Name_S7E_fuST/WE- flosP umveesery pf Ato
Hospital Address _ BU PS” Cove sre aarwEeecve Apal)
ity _$MavrRerc
StaterProvince_CP UE AEC
ZIP Code BT /e&s
‘Country CANARD A-
PCY: (e9. 1. 2@ete.) Clintemship (Residency C Fellowship [Research Clother
Depermenspecsy o8-ayn/
From: NY) 19%, To: JYNEW 19 %9 — successtully Completed? Yes J No [1 in Progress [)
Month Year Month Year
I
foowentnane CAMPBELL , AeA Loma VULY (foo F-
Coren ens son Fom
veaes Ah 6. Postgraduate Training (continued)
FE sospital Name sre lustre fesP, univeescry of MEdT7CeAc
Hospital Address_ 3/7 S Cope sre. cA7HvEQwe Kab
City
State/Province
ZIP Code, HBT (CS
County,
pov: 03.123) Clnenaip reianey Cfelmne CiRemmh Cote
Depariment/Speeialy: OB-GYA) ~ PERINATOLOE
rom ef) 19279 1 Seas L9F4 Successfully Completed? YesiZ} No] In Progress}
Month Year Month Year
Frost Name Morel NweU pe8R, Lanversiry OF ManrheAl-
Hospital Addres: BEYO 357 vRGAM) 97 -
City. MowT REPRE
State/Province Quebec
ZIP Code Haw 1 TE
Country CHVADLA
PGY: (eg., 1,2, 2, Ciintemship (Residency 1] Fellowship 1] Research [Other
Departmenvspeciaty. __ OB-@YA)___eNcoLoaY
From (PPO to MAR (90 ‘Successfully Completed? Yes (&L No] n Progress []
Month Year ‘Month Year
fenicatname: OM PPRELL HAW Looe _ fi
Conan gras enon om
emer es 6. Postgraduate Training (continued)
rospat Nome WOTRE -PAME pos P 5 SMR TY FE Mons REAC
Hospital address 0 SHR BRonke. EAST _
city Mo an eedte _ - poe
SaterProvince a
2IP Code a o MA a _
County CAMAD A
PCY: (e.9.,1,2,3,€4e.) Cintemship Residency C) Fellowship C]Research other
Department/Specialty: OB -GYA) {1 FeeT) “i7zy
FomPYliLs /G%0 refine 1 1GFO __successtity Compleea? Yespi NaCI in ProoresC]
Month Year Year
4.Hospital Name. syeswerns POS! - pores Lied pos
Venta ai OVI core sie. Seite fab > 38¢0 srURBA
Sree oa
enorme’ Qeeee
ZIP Code
‘Country. CANADA
Poy: (00.1238 Ciintemship D&Residency C Fellowship [] Research Clother
Department/Specialty CHEF fCeS MET In 08-6yYA) sénnpey CeuTEe.
From: *Y Ye) 1929 ro: owes J PPO successtuly Completed? Yes ka NoLJIn Progress (]
‘Month ‘Month Year
pC
epican Name: CAMPBELL Has L- _ owe, _ led | fase?
srry imennrom USING AUS
7. Examination History: If you aré not using FCVS, you are responsible for contacting the appropriate examination
entity and having a certified transcript of your scores sent directly to this Board
sea Examlnation History
List each licensure examination, U.S. of international, you have taken (USMLE, NBME, NBOME, LMCC, Ete. )fadkition-
‘al space is necessary please enclose a separate sheet with your application and include all the information below,
Examination Most Recent Date taken(Month/Year) Passed (P) or Falled (F) Number of attempts
State Board exam QO MeGen , LIF ee OF t
sate M/E"? wor MALDATORY FoR Specialists sa/ Chel W/9F4
FLEX Pre-1985 OP OF —s
FLEX Component 1 Op OF aaa
FLEX Component 2 oe oF ee
LMCC - Single Oe oF
LMCC = Part | _ Oe OF =:
McC = Part It . Op oF
NBME Part | Oe OF
NBME Part II Oe OF
NBME Part III Oe OF
SPEX Op oF
NBOME Part 1 Op oF
NBOME Part Ii Op oF
NBOME Part Ili Op OF
COMLEX Level 1 - Oe oF -
COMLEX Level 2 Oe oF
COMLEX Level 3 Op OF
‘COMVEX = oe OF
USMLE Step | a ge oF
USMLE Step II OP OF
USMLE Step III _ Oe oF _
eS
ropicant Name: CAMPBELL Wedd Coates fe / LAB L-
Common License Applicaton Form
Page 6 vse FeVS
8. ECFMG: If ECFMG is applicable and you are not using FCVS, you are responsible for contacting ECFMG and hav-
ing a certified "Status Report” forwarded directly to this Board. There is a Separate fee for this report. Reports can be
obtained through the ECFMG web site at wiwwectmg.org.
8.ECFMG (ifapplicabley — V/A
Certificate Number_ Issue Date Valid Through Date -
9. State or Professional Licensure: List all state and Canadian provinces where you currently hold or have ever
held any type of medicaVosteopathic license. You must also complete the attached Licensure Verification” form (Form
#1) and forward it to all states in which you have held any health care license or certification. The verifying entity must
{forward all documentation directly to this Board. Some state boards charge a fee for this information. Contact the state
board where you hold or held a license to determine their requirements.
9, State Licensure ~ MD or 00 only ~ attach additional pages if necessary
1 satpmincy MA rps MD rience tunber GOLD sarehe7 rss ooo CL ITZ.
(0,00, s) LAP Gee be
MD iconco number TEIBZ _ sarys MOTs date CAWATE 12517
3, SaiemProvince Type conse Number satus Issue Dato
4. SatsProvine Licence Number —_____stahis___ lee Dato
5. SatoProvince ____Type___Uvenge Number ____ Status leave Date
0 oa
6, SateProvinee Type Liane Number sas ise Dae
0 05,
7. StateProvince Type License Number Stas tssuo Dato
€. StateProvince Type License Number Staus___leue Date
03,30
@.StateProvince ___Type__License Number _ sttus___ sve Dato 7
to.siateProvince___Type___Lcense Number sts Issue Date
0b. ee
epicanname: CAMPBELL, Apis Lome Suey 1 00% _
Common License Application Form
Page7 ‘Ail Other Health Gare Licensure/Gertification (e.g, RN, PA, eto. - attach additional pages if necessary.
ie
1. State/Province ___Type_____ License Number __ Status Issue Date__
2. State/Province _ Type. License Number ___Status_ Issue Date__
3. State/Province _ Type. License Number ___ status, Issue Date
4, State/Province ‘Type License Number _____ Status_____Issue Date___
5. State/Province Type____ License Number_Status__Issue Date.
10. Chronology of Activities: List ALL activities (medical and non-medical) in chronological order beginning with med-
ical school graduation to the PRESENT date, using MONTH and YEAR. For any non-working time, you MUST state on
the form exactly what your activities were, such as "vacation" or ‘seeking employment,” as wel! as your permanent
‘address. if you worked for a physician-staffing group or did locum tenens, you must list all facities where you worked
‘and include complete dates and addresses. DO NOT SUBSTITUE ANY OTHER RESUME FOR THIS FORM. Be sure
to indicate the percentage of working time spent in clinical administrative duties.
10. Chronology of Activities (copy and attach addtional pages if necessary)
EE eC areo
Practice/Employment Name_STE-slus7iwé UMereese?y KoSPL7%e
(erst non-working tine 2 indicated above)
Praclookmployment Address RIES Core. sve onrnceve kitd
City, OMY REAL
State/Province. eb —
ZIP Code eft 5 Country —SAWAB,
Position and Department STAFF -06-GYA 4 Clinical LD _% Administrative.
Employment 0 Staff Privileges Affiliation] Other___
fee say | Peterinponment tame Alert oF aiebecrals - SHALE Ae beOnd CENTEL SHtcLM post)
enn SEPI—_ | (orlstnonnorting ne as hele above)
owe 28: PracticeEmployment Address XL AA CH LAUD AVE a
eee
te: State/Province. a
sonm MET VAL | 1p Code. AF FO Country 2S AL
reac Position and Department _GB—G7AS— % cinica % Administrative
Employment (] Staff Privileges DE_flaton [other
6
From: Practicelimployment Name. WT HORRE OE °GYAD
se _ | Gortsteonneetngline ts nacheg tere
ver. “ZBI _ | — racticevEmployment Address J Basroa) Sv xP
city Aas -
To SaterProvince —_ =
Monn: ACTPAK | zip Code OLGOS Country —_ 25 f—
Peston an Deparment OB-GYAF canvas ZB ve sarunspine LP
Employment [1 Staff Privileges (J Affiliation) Other PAA Rerice,
Applicant Name:
owe Vvey of oan F-
CHAP RELE Ae AdS &
Common License Aspication For
Page 9 VARA
eos
PracticelEmployment Name_fssveat7ed (UY aieea vs “Ke Pho
(ort eomrng tne a8 bata ove)
PracticerEmployment Address BEACow)
Oy a SI ta Fe a
To State Province
Mont ZIP Code _ ___ Country oe
ear Z490e_| Position and Department GIWECELGY _ % Ciinical_/BW% Administrative —__
Employment Staff Privileges [] Affiliation [J Other
REPRO went ooT af Bvuwess «WV 200F-
at
From PracticelEmployment Name Za 00 aiymerny rr Menezrr CONTE
ion (orttnomwetting hve ts coated sbove)
TAFE | pracceremployment Adiress P29 Uayeal Sr
city Lynas
To: StaterProvinee —— 47 -
tot ZIP code a4 ol County__ 75
heen 49S Postion and Department GYNECOLOGY ¥ clinical _/2)_.% Administrative
Employment 6 ‘Staff Privileges C] Affiliation = Other
e4 Locum FeHAVS
From: Practice/Employment Name MAL THA “S ViNEYAeD KESPLI
te {ors rorring tinea: Heeatd above)
pes: LF PE | practoerEmpioyment aderess LTH’ Ra,
City. o. S = MARTHHS WEY AR:
To: Slate/Province: 7
Mont ZIP Code. OASSE county__ USA
fear: Postion and Department OB-G YA/ _ % clinica LOT % neministratve
Employment EE ‘Staff Privileges 1) Affiliation J) Other.
6.
From Practice/Employment Name___
Monty —__ | _(ordstromwestng tne a reatd above)
er | Practicermployment Address — oe
hye
To State/Province
Mont: |Z Code — - country —
Year| Postion ang Department — % Clinical % Administrative ———
Employment (] Staff Privieges C)_—Affliaton -]. Other
Applicant Name vate Wey 1 00
CAmeR8 , Aen —
‘Common License Application Form
Pages A) Affidavit and Authorization for Release of Information: You must attach a recent (less than 6 months old)
passport quality, color photograph of yourself to this form, Take the form to a notary public and sign the form in
the presence of the notary public. The notarized form then must be sent direcly to this Board.
Affidavit
And
Authorization For Release of Information
|, the undersigned, being duly sworn, hereby certily under oath that | am the person named in this application,
that all statements | have or shall make with respect thereto are true, that | am the original and lawful possessor
and person named in the various forms and credentials furnished or to be fumished with respect to my applica-
tion and that all documents, forms or copies thereof furnished or to be furnished with respect to my application
are strictly true in every aspect
| acknowledge that | have read and understand the Application for Physician Licensure and have answered all
questions contained in the application truthfully and completely. | further acknowledge that failure on my part to
answer questions truthfully and completely may lead to my being prosecuted under appropriate federal and stale
faws.
| authorize and request every person, hospital, clinic, government agency (local, state, federal or foreign), court,
ascociation, institution or law enforcement agency having custody or contol of any documents, records and
other information pertaining to me to furnish to the Board any such information, including documents, records
regarding charges or complaints fled against me, formal or informal, pending or closed, or any other pertinent
data and to permit the Board or any ofits agents or representatives to inspect and make copies of such docu-
ments, records, and other information in connection with this application.
hereby release, discharge and exonerate the Board, its agents or representatives and any person, hospital,
lini, government agency (local, state, federal or foreign), court, association, institution or law enforcement
agency having custody or control of any documents, records and other information pertaining to me of any and
all fail of every nature and kind arising out of investigation made by the Board.
| will immediately notily the board in writing of any changes to the answers to any of the questions contained in
this application If such @ change occurs at any time prior to a license to practice medicine being granted to me
by the board
| understand my failure to answer questions contained in this application truthful
derial, revocation, or other disciptinary sanction of my licensure or permit to pra
be signed in the presence ofa notary)
C6, ada ze
LG, 20D 7~ _
Dale of Signature
Dated Toh) We Dev Isignea_*
state ot Maso qetracalts
‘SUBSCRIBED AND SWORN TO before me thi
My commission expires:
Applicant Name:
‘Common License Application Form
Page 11
date: fed 1 FE RECEny
ADDENDUM TO APPLICATION TLS
ewer “yes” to any of those question HR apin on
nal 8 1/2" x 11” sheet{s) if necessary.
NEGEIY
Please answer the following questions. if you
the reverse side of this sheet, or attach an addit
YES NO.
1. Are you certified by an American Specialty Board? (I yes, pro- v
vide 8 notarized copy of all certificates)
2. Have you ever, for any reason, lost American Specialy Board
Certitcation? v
3. Have you been denied required recertification by any specialty,
boards? (IF yes, list each boards and dates denied). Ze
4. Has any medical malpractice suit been brought against you or
has any claim been settled on your behalf in the last ten ek
years? (Iso, indicate how many). pa
5. Have you ever applied for licensure or to sit for an examina-
tion, or taken an examination, under a different name?
6. Have you ever been denied the privilege of taking or finishing
‘an examination or been accused of cheating or improper con-
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